Psychiatric Disorders and Sleep

PLEASE AM Requesting for ( Writer : CarolK (1609)) She wrote order number 225998 .the discussion post are on same case study. I WANT HER TO COMPLETE THIS ORDER.

Respond to MsBatis’ Post, and address in one of the following ways:

A.) If Bati’s posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.

B.) If you think your Bati might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.Psychiatric Disorders and Sleep

1 page please with 2 scholarly peer review references not more within 5yrs

Batis ‘s initial discussion post

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.

What time do you take your blood pressure medication? This patient has been prescribed a diuretic. Taking this medication at night can cause this patient to make several bathroom trips that will disturb her sleep. Getting this information will help make sure the patient understood the prescriber’s instructions on when to take the pill.

Do you have trouble obtaining prescribed medications or taking them?

This is a very important question because compliance to prescribed medication can help relieve symptoms. If this patient’s depression is getting worse, we need to know if the patient has access to her medication and if she is taking them as prescribed. Financial burdens can cause patient to skip medication doses or avoid taking them at all.

ORDER A PLAGIARISM -FREE PAPER NOW

What is your bedtime routine?

Sleep hygiene is very essential to promote sleep. If this patient takes coffee or other CNS stimulants before going to bed, she will have trouble falling her sleep. Insomnia may be due to intake of some stimulants so determining the patient’s bedtime routine can help find the cause of the problem.

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.

It will be important to involve those who know the patient’s daily routine and possibly observe the patient during sleep hours. In this case, whoever lives with the patient, be it family or a caregiver can provide information. Asking them the patient’s bedtime routine will be helpful. It is very important to know this patient’s bedtime routine to be able to determine how long she has been having sleep problems. The family or caregiver should be asked if the patient has current life stressors that are affecting her sleep. This information is important because psychological stressors, anxiety and depression can cause insomnia or worsen problems with insomnia. SSRIs can also cause insomnia so knowing if the problem started after the client started the medication can call for the therapy to be augmented.Psychiatric Disorders and Sleep

Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.

Physical exams needed for persons having problems sleeping and symptoms of depression can include CBC, CMP, TSH, UA, and EEG. Results from these tests will allow the practitioner to know what medications would be appropriate or perhaps if TSH was off would indicate the need to correct this before moving forward as this could be the reason for insomnia and mood problems. Creatinine would be looked at to determine kidney function along with liver studies for liver function. Drug screen should be performed to ensure that the patient is not using any controlled substances.

Polysomnography can be done to assess sleep apnea. Polysomnography is very important because it measures specific sleep characteristics and helps to diagnose sleep disorders. This study shows reports of different stages of sleep from light to deep (Wong & Ng, 2015)

Hamilton Depression Scale will be used to determine if the patient’s depression is actually worsening like the patient reports.

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why

-Insomnia

-Major Depressive Disorder.

Diagnosis of insomnia can be made if a patient has trouble falling or staying asleep for more than 3weeks. With insomnia, you have trouble falling asleep, staying asleep or having good quality sleep though you have a favorable environment to promote sleep (\”Insomnia,\” n.d.)

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.

Based on the presenting symptoms, I will order Mirtazapine 7.5mg oral nightly and Venlafaxine 37.5MG. The SNRI Venlafaxine will inhibit serotonin more potently than it will inhibit norepinephrine while Mirtazapine while inhibit both serotonin and norepinephrine (Stern et al., 2015). Given the patient’s history of hypertension, I will try to avoid a potent norepinephrine inhibitor to avoid hypertensive crisis. The choice is to get an antidepressant that can promote sleep and avoid potent serotonin inhibitors to avoid serotonin syndrome. Mirtazapine will be used at night due to its sedating effect while promoting norepinephrine and serotonin reuptake to enhance remission.

For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?

onsidering the fact that this patient was Asian, the prescription will be less than half the usual starting dose. Asians are prescribed less than half the usual starting dose to minimize the risk of adverse effects. Asians are prescribed lower doses due to lean body mass and medications that are metabolized in the CYP4502D6 are metabolized slowly by Asians (Chen et al., 2002).

Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.Psychiatric Disorders and Sleep

At four weeks, I will recommend the patient returns for reevaluation of depressive symptoms and if the medication the patient is taking is actually helping her to sleep. Therapeutic effects of most antidepressants usually takes weeks to months (Machado-Vieira et al., 2010). However, the sedating effect of Trazodone should be felt minutes to hours after the medication is ingested because it is rapidly absorbed after oral administration and reaches peak levels between 1-2 hours (Stern et al., 2015). Also, I will recommend a kidney function test because the patient is taking several medications that require renal clearance. Coupled with history of hypertension and polypharmacy, there may be need for dose adjustments if these medications are so hard on the kidneys.

References

Chen, J. P., Barron, C., Lin, K. M., & Chung, H. (2002). Prescribing medication for Asians with mental disorders. The Western journal of medicine, 176(4), 271–275.

Insomnia. (n.d.). NHLBI, NIH. https://www.nhlbi.nih.gov/health-topics/insomnia

Machado-Vieira, R., Baumann, J., Wheeler-Castillo, C., Latov, D., Henter, I., Salvadore, G., & Zarate, C. (2010). The timing of antidepressant effects: A comparison of diverse pharmacological and somatic treatments. Pharmaceuticals, 3(1), 19-41. https://doi.org/10.3390/ph3010019

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2015). Massachusetts General hospital psychopharmacology and Neurotherapeutics. Elsevier.

Wong, S., & Ng, B. (2015). Review of sleep studies of patients with chronic insomnia at a sleep disorder unit. Singapore Medical Journal, 56(06), 317-323. https://doi.org/10.11622/smedj.2015089

NO 2 DISCUSSION

1page please with 2 scholarly peer review references not more within 5yrs

Respond to Jennifer post and address in one of the following ways:

A.)          If Jennifer’s posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.

B.) If you think your Jennifer might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.

2.) Jennifer‘s initial discussion post

A case is presented to the class concerning a 75-year-old elderly woman whose chief complaint is insomnia. She also complains of worsening depression. Some co-morbid factors to consider are that she had been diagnosed with DM and HTN.  Her current medications include; Metformin, Januvia, losartan, HCTZ, and sertraline. Her depression began after her husband of 41 years passed away ten months ago. The aim of this discussion post is to respond to specific questions while including rationales for each response.

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.

At what time of day do you take your sertraline?

If Sertraline is taken at night there could be an increased risk for insomnia (Wichnaik et al., 2017).

Do you have a history of snoring or being told you stop breathing a night?

This question is of importance as sleep apnea is extremely prevalent in older adults (more that 20%) (American Psychiatric Association (2013).

Do you practice sleep hygiene?

This question assesses if the individual know what healthy sleep habits are. It is recommended that sleep hygiene be promoted before sleep medication is used especially in the older population (Clifford, 2018)

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.

This author would want to speak to any close relatives that would be able to confirm any changes in the patient’s behavior or who have seen the patient sleeping as long as the patient agrees to them being an informant.Psychiatric Disorders and Sleep

Questions

Have you noticed your loved one snoring loudly or quit breathing while sleeping? Family members are usually the first ones to notice sighs and symptoms of sleep apnea (Suzuki, et al., 2017).

Have you noticed any disorientation, changes in memory, or changes personality? Psychotic symptoms, agitation, apathy, depression, and sleep disturbances can indicate Alzheimer’s disease and other dementias (Lanctôt et al., 2017). These symptoms may be seen more at night time.

Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.

1)    PHQ-9 – The PHQ-9 can be used so assess the severity of depression (Levis et al., 2019) which can be the cause of insomnia.  Medical illnesses should be screened first when diagnosing insomnia (Suzuki et al., 2017).

2)    Polysomnography – Polysomnography can be used to assess sleep apnea, or insomnia disorder (American Psychiatric Association, 2013).

ROS –  The review of systems can help determine what type of sleep disturbances are occurring, and help in developing the differential diagnosis.  An assessment of naps, sleep/wake time, and hours of sleep should be assessed (Suzuki et al., 2017).

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.

1)    Persistent Insomnia Disorder with Other Medical Comorbidity (MDD).

2)    Sleep Apnea

3)    Situational/Acute Insomnia

This author feels that the patient is most likely suffering from Insomnia Disorder. This is a disorder that can be diagnosed as comorbid with another mental disorder and includes disturbances that cause distress, is ongoing for at least three months, happens despite adequate opportunity for sleep, and involves complaints of sleep dissatisfaction (American Psychiatric Association, 2013). Insomnia disorder has a higher prevalence in older females (American Psychiatric Association, 2013).

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.Psychiatric Disorders and Sleep

Jennifer‘s initial discussion post

Bati’s post influenced my understanding on concepts related to mental illness and insomnia. He is has selected very relevant questions to ask the patient regarding her current health status. His discussion of the reasons for asking the questions is also well thought and presents a clear picture of the sleep problem and the likely causative factors. He examines the current medication, the chief complaint of the client and general subjective data that builds up the patients HPI.

Moreover, the choice of people to ask about the patient’s condition is well examined. He gives a general overview of the individuals that could be involved with the patient. He also gives a realistic overview of what these individuals should be asked in order to build up the patient’s history. This is relevant in determining the preexisting medical conditions as well as genetic illnesses that could be possibly running in the family. This would call for an interview with a family member probably. However, I wish Bati was more specific on the relevant persons in the client’s life to inquire information from.

On the physical examination of the client, Bati provides a wide range of possible tests that could be undertaken to obtain a differential diagnosis. The results of these tests would be important in the diagnosis and treatment of the patient. Many diseases cause insomnia and hence it was important to conduct as many diagnostics.

The choice of pharmacological approaches is relevant to the patient’s condition. According to Stern et al. (2015), Mirtazapine is an effective treatment for depression that occurs with insomnia. Therefore it is critical in managing both problems at once. However, this drug can still cause multiple side effects including drowsiness that we seek to treat (Shuman et al., 2019).

References

Shuman, M., Chukwu, A., Van Veldhuizen, N., & Miller, S. A. (2019). Relationship between mirtazapine dose and incidence of adrenergic side effects: An exploratory analysis. Mental Health Clinician, 9(1), 41-47.

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2015). Massachusetts General hospital psychopharmacology and Neurotherapeutics. Elsevier.

PLEASE AM Requesting for ( Writer : CarolK (1609)) She wrote order number 225998 .the discussion post are on same case study.I WANT HER TO COMPLETE THIS ORDER.

Respond to MsBatis’ Post, and address in one of the following ways:

 A.) If Bati’s posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.

B.) If you think your Bati might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.

1 page please with 2 scholarly peer review refrences not more within 5yrs

Batis ‘s initial discussion post

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.

What time do you take your blood pressure medication? This patient has been prescribed a diuretic. Taking this medication at night can cause this patient to make several bathroom trips that will disturb her sleep. Getting this information will help make sure the patient understood the prescriber’s instructions on when to take the pill.Psychiatric Disorders and Sleep

Do you have trouble obtaining prescribed medications or taking them?

This is a very important question because compliance to prescribed medication can help relieve symptoms. If this patient’s depression is getting worse, we need to know if the patient has access to her medication and if she is taking them as prescribed. Financial burdens can cause patient to skip medication doses or avoid taking them at all.

What is your bedtime routine?

Sleep hygiene is very essential to promote sleep. If this patient takes coffee or other CNS stimulants before going to bed, she will have trouble falling her sleep. Insomnia may be due to intake of some stimulants so determining the patient’s bedtime routine can help find the cause of the problem.

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.

ORDER A PLAGIARISM -FREE PAPER NOW

It will be important to involve those who know the patient’s daily routine and possibly observe the patient during sleep hours. In this case, whoever lives with the patient, be it family or a caregiver can provide information. Asking them the patient’s bedtime routine will be helpful. It is very important to know this patient’s bedtime routine to be able to determine how long she has been having sleep problems. The family or caregiver should be asked if the patient has current life stressors that are affecting her sleep. This information is important because psychological stressors, anxiety and depression can cause insomnia or worsen problems with insomnia. SSRIs can also cause insomnia so knowing if the problem started after the client started the medication can call for the therapy to be augmented.

Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.

Physical exams needed for persons having problems sleeping and symptoms of depression can include CBC, CMP, TSH, UA, and EEG. Results from these tests will allow the practitioner to know what medications would be appropriate or perhaps if TSH was off would indicate the need to correct this before moving forward as this could be the reason for insomnia and mood problems. Creatinine would be looked at to determine kidney function along with liver studies for liver function. Drug screen should be performed to ensure that the patient is not using any controlled substances.

Polysomnography can be done to assess sleep apnea. Polysomnography is very important because it measures specific sleep characteristics and helps to diagnose sleep disorders. This study shows reports of different stages of sleep from light to deep (Wong & Ng, 2015)

Hamilton Depression Scale will be used to determine if the patient’s depression is actually worsening like the patient reports.

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why Psychiatric Disorders and Sleep

-Insomnia

-Major Depressive Disorder.

Diagnosis of insomnia can be made if a patient has trouble falling or staying asleep for more than 3weeks. With insomnia, you have trouble falling asleep, staying asleep or having good quality sleep though you have a favorable environment to promote sleep (“Insomnia,” n.d.)

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.

Based on the presenting symptoms, I will order Mirtazapine 7.5mg oral nightly and Venlafaxine 37.5MG. The SNRI Venlafaxine will inhibit serotonin more potently than it will inhibit norepinephrine while Mirtazapine while inhibit both serotonin and norepinephrine (Stern et al., 2015). Given the patient’s history of hypertension, I will try to avoid a potent norepinephrine inhibitor to avoid hypertensive crisis. The choice is to get an antidepressant that can promote sleep and avoid potent serotonin inhibitors to avoid serotonin syndrome. Mirtazapine will be used at night due to its sedating effect while promoting norepinephrine and serotonin reuptake to enhance remission.

For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?

Considering the fact that this patient was Asian, the prescription will be less than half the usual starting dose. Asians are prescribed less than half the usual starting dose to minimize the risk of adverse effects. Asians are prescribed lower doses due to lean body mass and medications that are metabolized in the CYP4502D6 are metabolized slowly by Asians (Chen et al., 2002).

Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.

At four weeks, I will recommend the patient returns for reevaluation of depressive symptoms and if the medication the patient is taking is actually helping her to sleep. Therapeutic effects of most antidepressants usually takes weeks to months (Machado-Vieira et al., 2010). However, the sedating effect of Trazodone should be felt minutes to hours after the medication is ingested because it is rapidly absorbed after oral administration and reaches peak levels between 1-2 hours (Stern et al., 2015). Also, I will recommend a kidney function test because the patient is taking several medications that require renal clearance. Coupled with history of hypertension and polypharmacy, there may be need for dose adjustments if these medications are so hard on the kidneys.

References

Chen, J. P., Barron, C., Lin, K. M., & Chung, H. (2002). Prescribing medication for Asians with mental disorders. The Western journal of medicine, 176(4), 271–275.

Insomnia. (n.d.). NHLBI, NIH. https://www.nhlbi.nih.gov/health-topics/insomnia

Machado-Vieira, R., Baumann, J., Wheeler-Castillo, C., Latov, D., Henter, I., Salvadore, G., & Zarate, C. (2010). The timing of antidepressant effects: A comparison of diverse pharmacological and somatic treatments. Pharmaceuticals, 3(1), 19-41. https://doi.org/10.3390/ph3010019

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2015). Massachusetts General hospital psychopharmacology and Neurotherapeutics. Elsevier.Psychiatric Disorders and Sleep

Wong, S., & Ng, B. (2015). Review of sleep studies of patients with chronic insomnia at a sleep disorder unit. Singapore Medical Journal, 56(06), 317-323. https://doi.org/10.11622/smedj.2015089

NO 2 DISSCUSSION

1page please with 2 scholarly peer review references not more within 5yrs

Respond to Jennifer post and address in one of the following ways:

A.)          If Jennifer’s posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.

B.) If you think your Jennifer might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.

 2.) Jennifer‘s initial discussion post

A case is presented to the class concerning a 75-year-old elderly woman whose chief complaint is insomnia. She also complains of worsening depression. Some co-morbid factors to consider are that she had been diagnosed with DM and HTN.  Her current medications include; Metformin, Januvia, losartan, HCTZ, and sertraline. Her depression began after her husband of 41 years passed away ten months ago. The aim of this discussion post is to respond to specific questions while including rationales for each response.

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.

At what time of day do you take your sertraline?

If Sertraline is taken at night there could be an increased risk for insomnia (Wichnaik et al., 2017).

Do you have a history of snoring or being told you stop breathing a night?

This question is of importance as sleep apnea is extremely prevalent in older adults (more that 20%) (American Psychiatric Association (2013).

Do you practice sleep hygiene?

This question assesses if the individual know what healthy sleep habits are. It is recommended that sleep hygiene be promoted before sleep medication is used especially in the older population (Clifford, 2018)

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.

This author would want to speak to any close relatives that would be able to confirm any changes in the patient’s behavior or who have seen the patient sleeping as long as the patient agrees to them being an informant.Psychiatric Disorders and Sleep

Questions

Have you noticed your loved one snoring loudly or quit breathing while sleeping? Family members are usually the first ones to notice sighs and symptoms of sleep apnea (Suzuki, et al., 2017).

Have you noticed any disorientation, changes in memory, or changes personality? Psychotic symptoms, agitation, apathy, depression, and sleep disturbances can indicate Alzheimer’s disease and other dementias (Lanctôt et al., 2017). These symptoms may be seen more at night time.

Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.

1)    PHQ-9 – The PHQ-9 can be used so assess the severity of depression (Levis et al., 2019) which can be the cause of insomnia.  Medical illnesses should be screened first when diagnosing insomnia (Suzuki et al., 2017).

2)    Polysomnography – Polysomnography can be used to assess sleep apnea, or insomnia disorder (American Psychiatric Association, 2013).

ROS –  The review of systems can help determine what type of sleep disturbances are occurring, and help in developing the differential diagnosis.  An assessment of naps, sleep/wake time, and hours of sleep should be assessed (Suzuki et al., 2017).

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.

1)    Persistent Insomnia Disorder with Other Medical Comorbidity (MDD).

2)    Sleep Apnea

3)    Situational/Acute Insomnia

This author feels that the patient is most likely suffering from Insomnia Disorder. This is a disorder that can be diagnosed as comorbid with another mental disorder and includes disturbances that cause distress, is ongoing for at least three months, happens despite adequate opportunity for sleep, and involves complaints of sleep dissatisfaction (American Psychiatric Association, 2013). Insomnia disorder has a higher prevalence in older females (American Psychiatric Association, 2013).

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other. Psychiatric Disorders and Sleep